An Indo-Australian app goes global

Low cost mobile technology developed in Australia and piloted in India shifts the dial on cardiovascular risk in rural Indonesia

NEW DELHI, AUG 29. An Indo-Australian-developed mobile app supported system that helps health systems identify and better manage people at high risk of cardiovascular disease has been shown to improve the use of appropriate medications and lower blood pressure in rural Indonesian communities. The application was developed in Australia and piloted in India with great success and is now being taken to other countries.

The study, published today in JAMA Cardiology, showed that 15% of high risk patients in Indonesian villages where the system was used were taking medications to manage their risk factors at follow up compared to just 1% receiving usual care, with the greatest difference being the use of blood pressure medication (57% vs 16%). Blood pressure was also lower in the intervention group at follow up.

Lead author and Chief Scientist at The George Institute for Global Health, Professor Anushka Patel, said that the system has the potential to improve the lives of tens of millions of people, particularly in low to middle income countries where cardiovascular disease (CVD) is on the rise.

“CVD is estimated to be the cause of one third of all deaths in Indonesia in 2016, but current data suggests that less than one third of those with moderate to high risk of CVD receive any preventive care. Early screening and appropriate management is crucial to reducing the incidence of cardiovascular events in susceptible individuals in Indonesia.”

SMARThealth is a mobile device-based clinical decision support system (CDSS) developed by The George Institute for Global Health that allows community health workers to assess CVD risk using basic equipment and refer those at high risk to nurses or physicians for further consultation.

Originally developed in Australia, the SMARThealth system is also being evaluated for a range of conditions in China, India, Thailand and Myanmar. The pilot study conducted in Bhimavaram, South India, showed that the system holds great promise and when this was replicated in Haryana in North India, the results were encouraging.

“In this study we deliberately set out to evaluate how effective our technology platform could be when embedded within the context of a complex local health system,” added Dr D Praveen, the global SMARThealth project director based at The George Institute, India.

“The results suggest that instead of reinventing the wheel, efforts should be directed towards culturally adapting and integrating many of the innovations and interventions from other low to middle income countries to strengthen health systems in Indonesia.”

The Indonesian study included 6579 individuals living in eight rural Indonesian villages in Malang, Indonesia who were identified as being at high risk of cardiovascular disease, defined by:

A 10-year predicted CVD risk ≥ 30%; (based on World Health Organization and International Society of Hypertension data)

A 10 year estimated CVD risk of 20-29%

Four of the villages were chosen for the intervention using the app and each was matched with one of four ‘control’ villages that received usual care. Baseline data was collected in September 2016 and follow up completed in March 2018.

After 12 months’ use of the system:

15% of those in intervention villages reported appropriate use of preventive medications compared to 1% in control villages

​56.8% of those in intervention villages used BP medication compared to just 15.7% in control villages.

“The baseline data from the study shows how great the need is for better approaches to improving cardiovascular health in middle-income countries – a tiny fraction of people at high risk of experiencing a heart attack or stroke were receiving any form of cheap and effective preventive medicines,” said Dr Sujarwoto, of the University of Brawijaya, who led the project in Malang.

“Controlling hypertension and other cardiovascular diseases through identification, follow-up, and lifestyle modification among people with high CVD risks should be a priority in both urban and rural areas.”

Previously evaluated mobile technology driven solutions to this problem have focused more on the technology itself, without taking into account the complexity of the healthcare systems in which they are deployed. The Indonesian health care system is highly decentralised and relies on local district health agencies to deliver care via nurses and community health care workers at neighbourhood and village health centres.

The Malang district government is now aiming to scale-up SMARThealth to around 400 villages over the next three years.

A consortium of researchers including the George Institute for Global Health, the University of Brawijaya and the University of Manchester have been funded by the Australian National Health and Medical Research Council to provide technical assistance for, and to evaluate, this scale-up.

The Malang study was funded by Give2Asia on the recommendation of The Pfizer Foundation and NHMRC program grant. The Pfizer Foundation is a charitable organization established by Pfizer Inc. It is a separate legal entity from Pfizer Inc. with distinct legal restrictions.